Mr. Jim Breslin:

Yes. There are substantial differences between what has happened in this instance and the infection of people through the blood supply at a time it was known that an issue was live and present. The overall challenge and comment is exactly correct. Patients have to be at the centre of the patient safety culture within healthcare. There are many other things we need to do, but that must be the primary focus of all health service practitioners. We need to build systems that support people to make safe decisions as they go about their duties and we need intelligence that spots things before they become a problem. I will give some examples of the scale of this. Every year, we have 3.3 million outpatient attendances, 1.3 million emergency department attendances, 1.6 million admissions to hospital and 20 million GP attendances. It is not enough to get 99% of those right. If we get 1% of them wrong, that has significant implications. That is the culture we need. A great deal of work will be needed in the health service. We will have to bring the community with us as we to try to break down the old-fashioned "doctor knows best" approach and replace it with a partnership with patients.